Be careful of diagnosis code in medical visits
Question: How do you handle dual-diagnosis cases under APGs?
Answer: The importance of a dual-diagnosis case depends on the nature of the patient visit and the payer’s policy regarding secondary diagnoses. Usually, a payer will accept only one diagnosis. Therefore, it is up to the medical record department to sequence the primary diagnosis or reason for the visit by importance.
If the patient visit is deemed to be medical and does not involve a surgical procedure or an ancillary service, the diagnosis becomes paramount to determining which APG will be assigned to the claim.
For example, a patient may present in an emergency department (ED) or hospital urgent care center with a severe sore throat and an unrelated gastric episode. The patient is treated for both symptoms with medications and sent home.
For APG purposes, the visit is regarded as medical and will be assigned a medical APG. The final diagnosis, therefore, becomes important because it will be what the payer’s grouper software will read in making the correct APG assignment.
In these cases, it is important that the primary ICD-9-CM code is entered into box 67 of the UB92 form. Usually, the primary diagnosis reflects what is determined as the more important of the two. The determination is based on the medical record coder’s level of experience or by checking with the attending ED physician’s notes. But check with your payer on how these claims are handled.
If you submit more than one diagnosis code on the basis of a "significant sign and symptom," the payer is likely to throw the claim into the highest paid medical category. That amount will vary among payers.
At Blue Cross of Washington and Alaska in Seattle for example, the highest paid medical category is currently weighted at 1.99 and the lowest at .40. When the conversion factor, which is the dollar amount negotiated with the hospital by the payer, is applied, the facility payments can swing dramatically.
Surgical and ancillary visits, the two other major types of visit categories, usually are not affected by dual diagnosis codes because they are procedure-based. The APGs are assigned by the nature of the reported procedure.
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content